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Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
Review ArticleCRAVING IN SUBSTANCE USE DISORDERSShobit Garg, Ambrish S. Dharmadhikari, V.K. SinhaAbstract
Drug addiction constitutes a chronic central nervous system disorder and one of the most seriouspublic health problems globally. Most prominent feature of addictive behaviour is craving which canbe described as the psychic pain of addiction. It is an intractable obstacle confronted by subjectswith substance use disorders attempting to achieve abstinence. Craving is the key factor behindcompulsive drug-taking behaviour. Direct relationship between craving and relapse, though notwell established, appears to occur through intermediate factors. Incorporating cravingmeasurements into routine clinical practice can increase the patient's capacity to recognize andmonitor his internal states that are related to substance intake and this can be used inrecommending appropriate treatment. Craving seems to be a nonunitary phenomenon, anddifferent kinds of craving with different mechanisms have been proposed, so it is conceivable thatdifferent drugs (including proposed immunotherapy) can be more or less effective in different kindsof craving.Key words: Addiction, craving, abstinenceINTRODUCTION
have an earlier age at onset, have more days of abuse in
The Webster's Dictionary (Neufeldt, 1990) has defined
a given month and take less time to become addicted
“crave” to ask for earnestly, to want greatly, and to yearn
with greater severity. Cocaine-dependent women also
for. Craving is an emotionally charged term and has
demonstrate greater depressive symptomatology,
irresistible, compulsive, appetitive and anticipatory
longer abstinence, higher levels of drug craving and
qualities. Craving is a poorly understood term used to
seek more help after relapsing while men have more
describe a variety of phenomenon related to subjective
antisocial personality disorders (Weiss et al., 1997). Also
and objective states that may lead to substance
women exhibit less cocaine addiction–related
pathology of the frontal cortex than do men (Chang et
World Health Organization (WHO) Expert Committees
on Mental Health and on Alcohol (1955) in 1954
THEORIES OF “CRAVING”
concluded that the term “Craving” was inappropriate
because of its everyday connotations. Later craving
1. Conditioning based models: Four models based on
entered into ICD- 10 as one of the diagnostic criteria
Ivan Pavlov's classical conditioning are: the withdrawal
World Health organization (1992) but it does not
model, the compensatory response model, the
feature in DSM IV diagnostic criteria (DSM IV merely
opponent process model, and the incentive
states that craving is “likely to be experienced by most, if
not all, individuals with substance dependence”)
In withdrawal model individuals seek to consume drugs
(American Psychiatric Association, 1994). Rankin et al.
in order to escape aversive state and to relieve
(1979) referred to craving as a generic “predisposition
withdrawal-related discomfort. Initially the lack of
to drink”, comprising all levels of desire, but Kozlowski &
drugs (an unconditioned stimulus) provokes a
Wilkinson (1987) used craving only to describe urgent
withdrawal syndrome (an unconditioned response).
desires. In spite of failure to reach a consensus in a
Associated with the lack of drugs are drug paraphernalia
meeting on craving by NIDA (US National Institute on
that become conditioned stimuli to the withdrawal
Drug Abuse) in 1991, craving is enjoying the renewed
discomforts. During abstinence, these cues may
interest in cue reactivity in relapse, neuroimaging and
provoke a withdrawal response (a conditioned
treatment modalities (MacKillop & Monti, 2007).
response) that is thought to create craving (Baker et al.,
GENDER DIFFERENCES IN THE CRAVING PROCESS
Whereas addiction is often attributed to men, women
The opponent-process and compensatory response
also are clearly affected. Cocaine-dependent women
models state that the withdrawal response should be
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
opposite to the direct effects of the drug and be
cerebral activity results in craving. In early withdrawal
correlated to the level of tolerance Baker et al. (1986).
state, craving occurs to alleviate the imbalance. In later
These also explain why craving appears in the abstinent
recovery state, the altered brain functions returns to
subjects long after the withdrawal symptoms have
their original state but cravings may appear suddenly.
This reactivation can be triggered by stress which may
The incentive model Stewart et al. (1984) posits that a
activate the reward memory (Anton, 1999).The reward
stimulus such as a bar becomes conditioned, thus
memories may also reactivate neurochemical processes
provoking similar physiological and psychological
associated with past experiences of drug use and cause
responses as actual drinking. If drinking does not take
place, craving occurs to appreciate the positive aspects
exposure causes allostasis, defined as ''a state of chronic
2. Cognitivemodels The various cognitive models
deviation of the regulatory systems with establishment
involving information-processing systems are as
of a new set point''. An allostatic state involves a feed-
forward mechanism rather than the negative feedback
mechanism of homeostasis. Overactivation of the brain
anticipatory effect of positive outcome expectancies
reward system triggers the brain stress circuit or
(beliefs) provoked by alcohol related cues. There is also
antireward system, in order to limit the reward. Long
motivational component i.e. intention to use, labeled
term drug intake dysregulates the underlying
''urge'' and one may experience a craving and not an
neurochemical functions (↓ Dopamine, ↓ Serotonin, ↑
urge – that is, be tempted but not intend to consume.
Corticotropin-releasing factor) resulting in an allostatic
model Urges are modulated by positive and
state. Antireward system and neurotransmitter changes
negative affect urge network (Baker et al., 1986). The
create powerful negative reinforcement. Craving arises
positive affect urge network has information on the
from the action of memory of the rewarding effects of
direct pleasurable effects of the drug. Negative network
drug use superimposed on a negative emotional state
provokes urge based on the negative affect. Baker et al.
(1986) suggested that positive expectancies of
Temporal-difference reinforcement learning model
desirable drug effects are probably coded into the
(TDRL)- In TDRL, actions are selected to maximize future
negative affect network: the drug is more desirable
rewards which are based on the strength of a value
signal, defined as the expected future reward
discounted by the expected time to the reward. This
drinkers accustomed to no limits are prevented from
value signal is carried by dopamine and produce
drinking. For example, an individual decides to consume
temporal-difference learning in the normal brain. TDRL
a drink but if an obstacle prevents consumption, craving
is based on assumptions about cocaine, which produce
happens, considered to be a non-automatic, effortful
a phasic increase in dopamine directly and push a
response (Tiffany, 1999). Alcoholics exposed to alcohol
person towards irrational behaviour (Redish, 2004).
cues had a slower reaction time on cognitively
demanding tasks and perceive an ''extended now''
refers to the sensations that originate from the interior
state, during periods of self-restraint resulting in relapse
of the body. The interoceptive state is mediated by
anterior insular cortex which has bidirectional
3. Psychobiologicalmodels These models are directly
connections to the amygdala and the ventral striatum.
influenced by biological neural systems (neural circuitry,
Alteration in interoceptive processing is due to an
reward systems, and neuroanatomical) and are as
altered ''prediction error'' which refers to the difference
between the value of the anticipated sensation (i.e., the
Neuroadaptive model- Craving is due to hyper-
hoped for result) and the value of the current
sensitization of the dopamine neural transmitter
interoceptive state. Dysregulation of insular cortex
system that in turn increases the incentive salience of
(minimizes the body prediction error) causing non-
drugs. ''Incentive salience'' makes stimuli more
adaptive adjustment of the body prediction error
attractive and turns ordinary wanting into excessive
causes craving in addiction process (Paulus et al., 2009).
drug craving (Robinson & Berridge, 1993). Drugs causeneurobiological adaptations to maintain homeostasis
4. Motivationalmodels The motivational models of
and if drug consumption ceases, an imbalance in
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
Motivational model of alcohol use- Final common
stereotypic thinking. The orbitofrontal is thought to
pathway to alcohol use is motivational and the strength
inhibit impulsive behaviour by sending evaluative
of the motivation depends upon the emotional state
information to the DLPC. Because the orbitofrontal
one wish to achieve (Cox & Klinger, 1988). A person's
cortex is connected through the DLPC to the basal
desire to drink depends on the degree of incentive
ganglia, its impairment may promote obsessive–
motivation. The model also takes into account
compulsive state. Individual memories interact with the
personality, historical factors, direct chemical effects,
judgment center of the orbitofrontal cortex in a highly
past reinforcement from drinking, situational factors,
specific way when an individual evaluates the level of
risk or reward in a given situation.Multidimensional ambivalence model- This model
TYPES OF CRAVING
consists of two parallel, motivational pathways,
There are three types of craving based on three-
approach (induces a craving) and avoidance (stops
pathway psychobiological model as proposed by
craving) and adds an ''evaluative space'' where these
competing motives intersect. Also, it adds the key
1. Reward craving, involves those people who consume
modulator ''access to alternative valued activities''. In
because of a desire for the positive effects of alcohol.
the evaluative space, four subgroups can be found:
The personality style is that of reward seekers, that is, a
approach, avoidance, indifference, and ambivalence.
high sensitivity to positive reinforcement or rewarding
Indifference consists of low approach and low
events. They seek the neurotransmitter chemical
avoidance, whereas ambivalence consists of high
reward involving the opioidergic/ dopaminergic system
approach and high avoidance (Breiner et al., 1999).
to compensate for a low level of cortical arousal.
5. Personality theories
2. Relief craving, involves those people who consume to
Eysenck's theory of personality says that subjects with
relieve tension or arousal. The personality style is stress
high extraversion have difficulties in acquiring
reactive. Relief craving is associated with aversive
conditioned responses due to lower sedation
motivational system or the behaviour inhibition system
thresholds and high neuroticism is thought to enhance
(BIS) (Gray, 1987). Relief craving is possibly due to a
conditionability (Eysenck & Eysenck, 1985). Because
dysregulation in the GABAergic/ glutamatergic systems
craving can be regarded as a conditioned response to
drug, lower extraversion and higher neuroticism,
3. Obsessive craving, involves those who are incapable
of controlling their intrusive thoughts about drinking.
According to Gray (1987), Behavioural Approach System
The personality style associated is characterized by low
(BAS) regulates aversive motivation and the
restraint or disinhibition, that is, ''the inability to
Behavioural Inhibition System (BIS) regulates appetitive
restrain impulses in the face of impending appetitive
motivation. High BAS sensitivity is reflected in
and aversive stimuli''. Obsessive craving may result from
engagement in goal-directed efforts when the person is
exposed to cues that predict reward.
Drummond (2000) also talked about ''cue-elicited
NEUROANATOMY OF CRAVING
craving'' (conditioned response to a cue) and
Anton (1999) proposed a neuroanatomical model
''withdrawal-related craving'' (during the withdrawal
based on clinical experience, brain-imaging, and
phase as an unconditioned response) with possibility of
laboratory data. Various drugs increase dopamine
levels in the nucleus accumbens. Three brain regions
Koob & Moal (2008) also gave two types of craving. The
are subsequently activated: the amygdala; the dorsal
first, Type 1, was induced by memory of cues that had
lateral prefrontal cortex (DLPC), the region where
previously been paired with drug use. Type 2 craving
reward memory are located, and the basal ganglia, a
consist of a Type 1 craving situation superimposed onto
region involved in repetitive thought and behaviour
a change in emotional state characterized by dysphoria,
patterns. The DLPC is also stimulated by sensory
anxiety, or a residual negative emotion.
information from the frontal cortex in addition to affect
ASSESSMENT OF DRUG CRAVING
from the amygdala and nucleus accumbens.
Both direct self-report questionnaires and indirect
The DLPC in return sends information and sensitizes
behavioural and physiological measures are used to
nucleus accumbens to future drug cues. In addition, the
assess the psychological experience of craving
DLPC transmits the memory to the basal ganglia that
may increase the craving reaction because of its role in
Single-item ratings of subjective craving- Single-item
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
Likert-type rating or visual analogue scale (VAS) are
There is now a range of medications available for each of
used to indicate the degree of craving. Paper-and-pencil
the major classes of addictive drugs: alcohol, cocaine,
forms, control knob, dial or joysticks to a computer are
used to record multiple repeated ratings of craving.
1. Anticraving drugs for AlcoholMulti-item self-report questionnaires- Various
Three US FDA approved medications for the relapse
questionnaires like Obsessive–Compulsive Drinking
prevention of alcohol are Naltrexone, Acamprosate and
Scale (OCDS) Anton et al. (1995); Obsessive–
Compulsive Drug Use Scale (OCDUS) Franken (2002)
one Naltrexone is approved by the US FDA in
and Temptation and Restraint Inventory (TRI) Collins &
1994 that diminishes the rewarding effects by reducing
Lapp (1992) are used to assess craving Rosenberg
dopamine in VTA (Ventral Tegmental Area) and nucleus
accumbens and release of endogenous opioids like
edures The instructions are similar
to the free association in psychoanalytic therapy, in that
It reduces craving for both dependent patients and
participants are asked to speak their thoughts aloud
social drinkers. There are reviews and meta-analyses,
without any judgment, except that they do so during
along with 29 published randomized placebo controlled
cue exposure or after imagining themselves in a drug
trials, some supportive and some not (Kranzler, 2000;
related situation (Shadel et al., 2004).
Richardson et al., 2008). Naltrexone significantly
Indirect or proxy measures of craving Various indirect
reduces craving and rates in heavy drinkers by 30-60%,
ways of assessing craving are as follows:
though abstinence is seen usually in 25-35% cases
dreams Substance-related dreams are the
Pettinati et al. (2006).The dose is 50-100 mg per day.
expression of unconscious wishes to resume drug use.
Potential barriers are non-adherence (at least 80%
The frequency and prevalence of substance-related
compliance with daily administration of the drug is likely
dreams are associated significantly, if only moderately,
A long acting injectable formulation of Naltrexone
2. Behavioural indications of craving- Proposed
(encapsulated naltrexone 380 mg in bio-degradable
behavioural indicators of craving in people include
microspheres) was approved by the US FDA in 2006.
latency to consume one's drug of choice, amount or
Therapeutic levels are maintained for a month. It also
speed of consumption, interpuff or inter-sip interval,
has reduced side effects and less chance of hepatic
and willingness to “work” for access to one's drug.
3. Psychophysiological measures ofe It was approved in 2004 in US for clinical
salivation (measured by dental rolls placed in the
use. It affects calcium channels and decrease in CNS
subject's mouth) predicts relapse following treatment,
excitatory system by reducing glutamate Dahchour &
though moderately. Greater self-reported craving and
DeWitte (2003). It has no abuse potential and has
eye blinks are found when smokers recalled smoking-
favourable side effect profile. Double-blind clinical trials
related sentences. Exposure to drug related stimuli
(1.3–3 g/day, orally administered) and meta-analysis
resulted in significant increase in heart rate in smokers,
have shown the efficacy of acamprosate in decreasing
problem drinkers and cocaine abusers (but not heroin
craving and maintaining abstinence (Mann, 2004).
addicts), and significant increase in sweat gland activity
Comparison between acamprosate and naltrexone and
in all four groups (Rosenberg, 2009).other drugs: Overall acamprosate showed increase in
4. Attentional bias- Performance on attention-related
the cumulative abstinence period, decrease the
tasks such as the addiction-stroop and dot-probe
likelihood of return to drinking, and better compliance
procedure may serve as proxy measures of subjective
(effect better with higher doses) compared to
craving. Longer reaction times on addiction-related
naltrexone. More recent studies of naltrexone have
words from contrast words, distinguish substance
found less favourable outcomes. Overall evidence
abusers from non-abusers, and predict relapse
favour acamprosate because of more number of studies
following a period of abstinence (Cox et al., 2006). Also
have been conducted with it, with longer duration, and
attentional bias is inferred by faster reaction time when
better acceptability in patient groups due to lesser
the probe replaces a drug-related stimulus than when it
adverse effects as compared to naltrexone. One
replaces the neutral stimulus (Rosenberg, 2009).
potential advantage of naltrexone (though not studied
ANTICRAVING MEDICATIONS
well) is its convenience of administration. Taking two
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
tablets of acamprosate thrice a day may be
Tiapride It has shown to promote abstinence, seems to
cumbersome for some patients and may affect
be well tolerated, although 4 cases of late dyskinesia
compliance as compared to the relatively simpler
have been reported (Shaw et al., 1994).
regimen of naltrexone one tablet per day (Dhawan &
ol It reduces alcohol intake in a rat model,
but the anti-alcohol effect is weakly selective and
Effect is synergistic when acamprosate is combined with
nonspecific. Pilot studies suggest its role in treatment of
disulfiram (Besson et al., 1998). Acamprosate is said to
substance abuse in psychiatric patients (Wiesbeck et al.,
be a cost effective treatment. However, in India,
Disulfiram is cheaper than either Naltrexone or
Methadone- Short-term methadone administration
Acamprosate (Dhawan & Jhanjee, 2007).
has shown to reduce alcohol consumption in heroin
Disulfiram It reduces the daily struggle against urges
addicted patients (Caputo et al., 2002).
toward alcohol. It is reserved for patients who have
Glutamatergic compounds- Memantine and
previously failed one or more courses of treatment or
lamotrigine have shown to reduce craving but in animal
who are motivated to achieve complete abstinence
models and further clinical studies are needed
(Brewer, 2005). Disulfiram use is now a second line
treatment after Naltrexone and Acamprosate. Several
2. Aniticraving agents for Cocaine
reviews support the efficacy (Suh et al., 2006) but lack of
Many agents have been tested and demonstrated to be
double blind controlled and randomized controlled
ineffective as treatment for cocaine dependence (Levy,
trials are hindrance. A long acting depot preparation in
the form of an implant has similar pharmacological
Various drugs such as dopamine antagonists
profile like oral Disulfiram (Johnsen & Marland, 1992).
(haloperidol, flupenthixol), dopamine-enhancing
No current research evidence is available on this
agent's (disulfiram and modafinil), dopamine agonists
(bromocriptine, amantadine, pergolide and levodopa),
en It (15 mg/day for the first three days and 30
topirimate, propranolol, vigabatrin, methylphenidate
mg/day subsequently) is effective in reducing intake,
inducing and maintaining abstinence. Also it has good
Disorder), buprenorphine, imipramine (in comorbid
tolerability and low side effects, without any risk of
depression), nifedipine and nimodipine have shown
abuse and also relieves symptoms of alcohol
some efficacy in reducing the reinforcing effects of
cocaine but further studies are needed (Grabowski et
al., 1994; Nunes et al., 1995; Compton et al., 1995;
e It (25–300 mg/day for 12 weeks) promotes
Handelsman et al., 1995; Kuzmin et al., 1996; Kampman
abstinence and reduces intake and craving. Recent
et al., 2002; Kampman et al., 2003; Carroll et al., 2004;
studies have shown to reduce addiction severity and in
Kampman et al., 2004; Hart et al., 2006; Levy, 2009; ).
increasing the patient's quality of life (Johnson et al.,
O t h e r d r u g s i n c l u d e m a z i n d o l , f l u oxe t i n e ,
carbamazepine, lithium, naltrexone and 4-iodococaine.Serotonin Reuptake Inhibitors and Ondansetron-
All have been postulated to alter reinforcing effects of
Fluoxetine (20 mg/day for the first 2 weeks then 40
cocaine. Comparative studies are still pending (Levy,
mg/day) has proved to be effective in reducing
depressive symptoms and alcohol consumption
3. Anticraving agents for Nicotine
together (Cornelius et al., 1997). Agabio et al. (2001)
Non-nicotine medications can be used in combination
showed that SSRIs might be useful in patients with late-
with nicotine replacement for nicotine cessation.
onset alcohol dependence, while ondansetron (0.5–4
Bupropion was approved by the FDA for smoking
mg for 6 weeks) could be effective in patients with early-
cessation. It reduces craving by action on dopamine.
Bupropion, alone (30.3%) or in combination with the
nicotine patch (35.5%), had superior abstinent rates to
detoxification of anxious subjects. A recent study,
the nicotine patch or placebo alone (Jorenby et al.
however, has not confirmed the efficacy of buspirone
versus placebo in decreasing alcohol consumption
Varenicline (approved in 2006 by the FDA as an aid to
smoking cessation) is a 4, 2 nicotinic acetylcholine
receptor partial agonist. Varenicline had significantly
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
greater abstinence rates at 12 and 52 weeks than
Table 1: Current status of vaccines in clinical trials
placebo or bupropion (Jorenby et al., 2006).
Rimonabant is a specific antagonist to cannabinoid
Drug-CarrierHuman Studies
receptor 1 (CB-1). Randomized controlled trials show
that rimonabant is effective for patients wishing to lose
weight and stop smoking. This drug is advancing through
the FDA approval process (O'Brien, 2005).
Nortriptyline and clonidine both appear effective, but
are considered second-line treatments (due to potential
side effects and lack of FDA sanction as smoking
cessation aids) (Marlatt & Witkiewitz, 2005).
4. Anticraving agents for Opiate Addiction
Strategy to maintain the patient with a medication in the
same pharmacological category (methadone orbuprenorphine) as the prior drug of dependence
PSYCHOLOGICAL MANAGEMENT OF CRAVING
enables a subject with opiate addiciton to function
Psychological treatment for reducing craving can be
normally with little or no drug craving. Naltrexone can
aid in the maintenance of the opiate-free state. If a
1. Procedures that are designed to decrease the
former addict “slips” and takes a dose of heroin while
likelihood of the onset of craving that include stimulus
taking maintenance naltrexone, the effects will be
control, cue exposure, aversion therapy, coping imagery
neutralized. Many report no craving possibly because
they learn that opiates are unavailable because of the
2. Procedures that are designed to decrease the
intensity and duration of craving include cognitive and
5. Anticraving agents for Inhalant abuse
S h a r p & R o s e n b e r g ( 1 9 9 7 ) r e p o r t e d t h a t
trol Externally triggered craving can be
pharmacotherapy is not usually useful in inhalant abuse.
reduced by minimizing exposure to the cues. Simple
Once detoxified, antidepressants, anxiolytics, or
avoidance of the situation is the best strategy especially
neuroleptics can be used as an adjunct to counseling,
in those filled with multiple cues for indulgence, before
depending on the problems that initially contributed to
coping responses are strong Marlatt & Witkiewitz
IMMUNOTHERAPY FOR THE TREATMENT OF DRUGCue Exposure- Cue exposure involves repetitive
exposure to cues, producing extinction of craving
Antibody therapy prevents drugs of abuse from entering
responses. It is most effective when exposure to drug
the CNS and reduce rush, euphoria. This is accomplished
cues is paired with strategies designed to combat
through a pharmacokinetic antagonism which reduces
everyday temptations. Efficacy in reducing relapse to
the amount of drug in the brain, the rate of clearance
alcohol, nicotine, opiates, and cocaine is seen.
across the blood–brain barrier and the volume of drug
Aversion therapy- Aversion therapy involves pairing
distribution. Active immunization with drug–protein
of alcohol cues with an aversive stimulus, a procedure
conjugate vaccines has been tested for cocaine, heroin,
by which alcohol cues come to elicit an aversive reaction
methamphetamine, and nicotine in animal and passive
rather than craving. In contrast to cue-exposure, the
immunization with high affinity monoclonal antibodies
goal of aversion therapy is to increase reactivity to
has been tested for cocaine, methamphetamine,
alcohol cues, because such cue reactivity is assumed to
nicotine, and phencyclidine in preclinical animal
reflect conditioned nausea. Increased bodily reaction
models. The specificity of the therapies (table 1), the
following aversive reaction should be associated with
lack of addiction liability, minimal side effects (itching
successful outcome (Baker et al., 1987).
and redness at injection site) and long-lasting protection
Coping Imagery- “Urge Surfing” technique can be
offer major therapeutic benefits Kosten & Owens
used to gain control by the patients. Client first labels
the internal sensations and cognitive preoccupations asan urge or craving and then fosters an attitude of
2012 Indian Association for Social Psychiatry
Indian Journal of Social Psychiatry, 2012, 28 (1-2), 43-52
detachment and disidentification regarding the wave of
and alcoholism.Expert opinion on therapeutic targets,
desire. Clients are initially taught the urge surfing
technique through guided imagery and then to try it on
American Psychiatric Association. (1994) Diagnostic and
their own whenever they are exposed to substance
statistical manual of mental disorders, Washington, DC.
cues. Clients are asked to include four D's: Delay,
Anton, R., Moak, D., Latham, P. (1995) The Obsessive
Distract, Drinking water, and Deep breathing (Marlatt &
Compulsive Drinking Scale (OCDS): a new method of
assessing outcome in alcoholism treatment studies.Self-Monitoring of Urges and Craving – The Craving
Archives of General Psychiatry, 53, 225–231.Diary: The client is asked to keep track of the internal
Anton, R. (1999) What is craving: models and
and external cues that stimulate craving, their mood,
implications for treatment. Alcohol Research and
the strength of craving, how long it lasted, coping skills
such as urge surfing used to cope with craving, and how
Anton, R.F. (2008) Naltrexone for the management of
successful or unsuccessful these coping strategies were
alcohol dependence, New England Journal of Medicine,
Baker, L.H., Cooney, N.L., Pomerleau, O.F. (1987) Craving
refuse like patient refusing a real glass of beer, thereby
for alcohol: Theoretical processes and treatment
learning to emit appropriate response under realistic
procedure. In: Cox, W.M., (Ed). Treatment and
condition, others being like asking a friend to forego
prevention of alcohol problems, pp. 184-199, Harcourt
drinking in one's presence (Baker et al., 1987).
Baker, T., Morse, E., Sherman, J. (1986) The motivation
the consequence of consuming or not consuming,
to use drugs: a psychobiological analysis of urges.
reappraisal of the situation, remembering one's
Nebraska Symposium on Motivation, 34, 257–323.
commitment to abstinence, remembering that cravings
Besson, J., Aeby, F., Kasas, A., et al. (1998) Combined
and desires for substances eventually go away, thinking
efficacy of acamprosate and disulfiram in the treatment
positive and tell oneself that she/he can fight off
of alcoholism: a controlled study. Alcoholism, Clinical
craving, talking oneself through the craving, praying or
and Experimental research, 22, 573-579.
asking for strength from higher power, practicing ahead
Breiner, M., Stritzke, W., Lang, A. (1999) Approaching
of time how to refuse substance offers (Baker et al.,
avoidance: a step essential to the understanding of
craving. Alcohol Research and Health, 23, 197–206.CONCLUSION
Brewer, C. (2005) Supervised disulfiram is more
There is a need to move away from clinically based and
effective in alcoholism than naltrexone or acamprosate
simplistic causal definitions and models of the
or even psychotherapy: how it works and why it
relationship between cravings and relapse. There is a
need for greater sophistication and standardization in
Caputo, F., Addolorato., G., Domenicali., M., et al. (2002)
methods of measurement of craving including further
The Services for Addiction Treatment: Short-term
development of research paradigms. With the arrival of
m et h a d o n e a d m i n i st rat i o n re d u c e s a l co h o l
new, promising medications aimed at preventing
consumption in non-alcoholic heroin addicts. Alcohol
relapse, there is a potential for better craving
measurement which would allow the identification of
Carroll, K.M., Fenton, L.R., Ball, S.A. (2004) Efficacy of
individuals that are most likely to benefit from drugs
disulfiram and cognitive behaviour therapy in cocaine-
thereby improving cost-effectiveness. Such research is
dependent outpatients: a randomized placebo-
likely to include the use of neuroimaging studies to
controlled trial. Archives of General Psychiatry, 61,
investigate the effects of medications on craving and
Chang, L., Ernst, T., Strickland, T., et al. (1999) Gender
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2012 Indian Association for Social Psychiatry

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